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NPI Code Detail

MEDICARE: KATRINA D. BLACK PA

MEDICARE: KATRINA D. BLACK PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician Assistant004612GA
2363AM0700XMedical Physician AssistantPA9110311FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1801194972
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATRINA D. BLACK PA
Provider Business Mailing Address
First Line : 10800 BRIGHTON BAY BLVD NE APT 3104
Second Line :
City : SAINT PETERSBURG
State : FL
Zip : 33716-3490
Country : US
Telephone Number : 912-292-7116
Fax Number :
Provider Business Practice Location Address
First Line : 3345 S DALE MABRY HWY
Second Line :
City : TAMPA
State : FL
Zip : 33629-7817
Country : US
Telephone Number : 813-234-0100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/14/2011
Last Update Date : 08/06/2021

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